O C T O B E R 2 0 1 5 O U T P A T I E N TS U R G E R Y. N E T 2 3
Take the ATM as an example. In older
models, users would consistently leave
their card behind, since the machine
sucked it in for the transaction and only
returned it at the end. To fix this, banks
made a hardwired technology change that
lets users keep their cards throughout the
process. In contrast, if designers had relied
on stickers or signs reminding you to take
your card, there still would be potential for human errors.
Unfortunately, there hasn't been a hardwired technology change like the evo-
lution of the ATM that ensures every operation goes perfectly every time. That
means the responsibility lies with your staff and physicians to mitigate any
potential risks. There's a risk of wrong-site surgery during every procedure.
Make that point perfectly clear to your staff and surgeons.
2. Time outs aren't enough
The Joint Commission's Universal Protocol is one of the most significant
advances in the fight against wrong-site surgery. And while it's a good place to
start, your prevention efforts should begin well before the day of surgery.
After a wrong-site surgery occurs, researchers look for factors that led to the
mistake. They often find they occurred in the days or weeks before the proce-
dure instead of in the OR. Consistently we find that the time out couldn't have
stopped the error — instead, it started way upstream. An incorrect consent, a
mismarked pre-op document or even the patient mistakenly identifying the
operation can lead to wrong-site surgery.
Because of that, your staff and surgeons must look for opportunities to pre-
vent wrong-site surgery throughout the entire surgical process, not just in the
OR. Every time patient information is passed along in your facility — includ-
z PAUSE POINT Time outs are effective if
staff and surgeons are active participants.
